3) Electric Burns caused by a) Low Voltage Electric Burns which causes direct injury to the tissues at the point of contact while the beneath bones and muscles may be damaged. B) High Voltage Electric Burns causes direct injury at the point of contact but also causes damages tissues underneath and conducts the electricity through the body. It causes damage at the site of the entry and site of exit and at the path through which it travels. The damage depends upon the amount of electric current passing, the resistance offered by the tissues wherein the skin offers the maximum resistance while the muscles, blood vessels and the nerves are the least resistant. The damage increases if the tissue is wet.
4) Chemical Burns caused by contact with strong acid or strong base. The severity of burns depends upon the concentration of the agent, the duration of contact and the amount of agent.
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5) Radiation Burns caused by X-Rays or Radium. It is type of Inflammation of Skin which is regarded as Burns. Two types: a) Acute Radiodermatitis which can cause usual changes of acute inflammation like erythema, oedema and exfoliation. It can also cause necrosis and deep indolent ulcer. b) Chronic Radiodermatitis occurs when Acute radiodermatitis has occurred previously or when small doses of Radiation is given for a long time. It can cause irregular pigmentation or depigmentation, telangieactases and indolent ulcers. It can also grow into Cancer.
6) Cold Burns caused by exposure to cold which includes freezing injuries (frostbite which is actual freezing of tissues with formation of ice crystals. It can cause tissue necrosis, microvascular occlusion, cellular dehydration, hyperaemia and oedema of skin) or non freezing injuries e.g. chilblain which is painful erythema in fingers, toes or ears produces by cold damp weather, Trench Foot which is found in mainly soldiers due to cold weather and circulatory disturbances caused by tight clothing, Immersion foot which is like trench foot found in waterlogged boats.
Pathology of Burns can be seen under two headings:
Local Changes: 1) Severity of Burns: First Degree burns cause hyperaemia and oedema of skin. There is no scarring. These burns heal rapidly. Second Degree Burns cause destruction of entire epidermis and causes blebs or vesicles which is the hallmark of Second Degree Burns. Subdivided into Mild and Severe. In Mild cases epithelium is left for growth of new skin and in Severe Cases no epithelium is left in dermal glands and hair follicles. Skin grafting is necessary. Third Degree causes complete destruction of the epidermis, dermis, dermal appendages and the sensory nerves. Skin grafting is obligatory.
Some Surgeon goes with the classification as Partial Thickness Burns and Full Thickness Burns.
2) Extent of Burns: Percentage of Burn surface is commonly estimated by â€œthe Rule of Nineâ€Â
Head, Neck and Face 9%; Right Upper Limb 9%; Left Upper Limb 9%; Right Lower Limb 18%;
Left Lower Limb 18%; Anterior Trunk 18%, Posterior Trunk 18%; External Genitalia 1%. This is for adults and differs in Pediatric cases.
3) Vascular Changes: there is dilatation of small vessels, increase in their permeability, local release of Histamine, and outpouring of exudates which is rich in Protein and which collects in the Blisters. On drying it forms dry brown crust.
4) Infections: In first Degree Burns the Skin is intact hence it serves as barrier to invading virulent organisms. In other Burns the Skin is broken hence the virulent organisms entre and cause infections. General Malnutrition, Anemia, loss of blood volume increases the severity of infections. This bacterialisation can also cause oligaemic shock.
B) Systemic Changes: they include four things 1) Shock 2) Biochemical Changes 3) Blood Changes 4) systemic lesions
1) Shock: a) Oligaemic Shock: Heat causes release of Vasoactive materials which increases the cell wall permeability which cause loss of fluid and proteins evident as oedema and blebs. There concentration of blood that leads to oligaemic shock. Sodium and Chloride levels decreases and Potassium levels increases which cause massive cell destruction and fluid loss which is described as Burn Shock. The blood supply to vital organs is affected due to hemolysis.
B) Neurogenic Shock due to extreme pain and anxiety
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c) Cardiogenic Shock due to fall in cardiac output result of increased peripheral resistance and decreased blood volume and increased viscosity of the blood.
d) Bacteriaaemic Shock due to infections and release of toxic materials. It may cause vomiting, delirium and bloody diarrhea, hemoptysis.
2) Biochemical Changes: a) Electrolyte imbalance in which there is decrease of Sodium and Chloride and increase in Potassium. b) Decrease in Protein c) Increase in Glucose d) Increase in Blood Urea and Creatinine
3) Changes in Blood: 1) Haemoconcentration due to loss of fluid. Hemoglobin may rise about 150% 2) Formation of clumps of white blood cells, platelets and red blood cells. It increases the blood viscosity. 3) Anemia due to destruction of RBCs
4) Systemic Lesions: 1) Liver: Shows focal areas of necrosis may also show Councilman Bodies like in Yellow Fever 2) Kidney: Get low Blood Perfusion and show haemoglobinuria. Slowly Oliguria and Anuria may develop. 3) Adrenals: becomes enlarges and swollen. May get necrosed at some areas. 4)Gastrointestinal Tract may show ulceration in stomach and Duodenum. They are prone for bleeding. Ulcers in Colon can also occur. 5) Pulmonary Changes: Pulmonary vascular resistance increases. It causes Pulmonary insufficiency and hyperventilation to the extent that the patient may require ventilator support. 6) Endocrine System: Glucagon, Cortisol and catecholamine level increase while Insulin level decrease. 7) Neurogenic Changes: sometimes delirium and disorientation can occur 8) Immune System Depression of Immunoglobulin, Lymphocyte, T cells level and neutrophil functions.
Treatment of Shock: i) Analgesic and sedatives are administered. ii) Fluid Resuscitation: should be started in all patients with more than 15% Burns in adults and 10% in Pediatric cases. Veins are usually collapsed so Venesection is often needed. Evanâ€™s Formula or Brookeâ€™s formula is used for fluid Transfusion. Oliguric cases are treated with more fluid transfer. Airway Maintenance: Patient may present with tachypnoea, hypoxia, respiratory arrest to Coma. Upper airway obstruction may be present in burns of head neck face regions.
B) General Treatment:
a) Tetanus prophylaxis b) Antibiotic c) Nutritional Support d) Gastric Decompression e) Treatment of Gastric Disorders f) Escharotomy and Fasciotomy
C) Local Treatment:
a) First Aid includes removing patient from source of heat and giving cold clean bath. B) Wound Care by Open or Closed Method. The burn area to be cleaned by surgical detergent and all non viable skin to be removed. The blisters to be punctured and the loose non viable skin are excised. Topical agents like Silver Nitrate and Cerium Nitrate is used on burns. C) Skin Grafting for timely closure of Burn Wound.
D) Physical Therapy and Rehabilitation is started due to contractures and deformities.
E) Support Groups
Complications: Curling Ulcers: these are stress ulcers of stomach and duodenum, Acute Pancreatitis, Acute Acalculous Cholecystitis, Contractures, deformities, Superior Mesenteric Artery Syndrome.